Using evidence to decision frameworks led to guidelines of better quality and more credible and transparent recommendations

BACKGROUND AND OBJECTIVES

To determine whether the use of Evidence to Decision (EtD) frameworks is associated to higher quality of both guidelines and individual recommendations.

METHODS

We identified guidelines recently published by international organizations that have methodological guidance documents for their development. Pairs of researchers independently extracted information on the use of these frameworks, appraised the quality of the guidelines using the Appraisal of Guidelines, Research and Evaluation II Instrument (AGREE-II), and assessed the clinical credibility and implementability of the recommendations with the Appraisal of Guidelines for REsearch & Evaluation Recommendations Excellence (AGREE-REX) tool. We conducted both descriptive and inferential analyses.

RESULTS

We included 66 guidelines from 17 different countries, published in the last 5 years. Thirty guidelines (45%) used an EtD framework to formulate their recommendations. Compared to those that did not use a framework, those using an EtD framework scored higher in all domains of both AGREE-II and AGREE-REX (P < 0.05). Quality scores did not differ between the use of the The Grading of Recommendations Assessment, Development and Evaluation-EtD framework (17 guidelines) or another EtD framework (13 guidelines) (P > 0.05).

CONCLUSION

The use of EtD frameworks is associated with guidelines of better quality, and more credible and transparent recommendations. Endorsement of EtD frameworks by guideline developing organizations will likely increase the quality of their guidelines.

Second international consensus report on gaps and opportunities for the clinical translation of precision diabetes medicine

Precision medicine is part of the logical evolution of contemporary evidence-based medicine that seeks to reduce errors and optimize outcomes when making medical decisions and health recommendations. Diabetes affects hundreds of millions of people worldwide, many of whom will develop life-threatening complications and die prematurely. Precision medicine can potentially address this enormous problem by accounting for heterogeneity in the etiology, clinical presentation and pathogenesis of common forms of diabetes and risks of complications. This second international consensus report on precision diabetes medicine summarizes the findings from a systematic evidence review across the key pillars of precision medicine (prevention, diagnosis, treatment, prognosis) in four recognized forms of diabetes (monogenic, gestational, type 1, type 2). These reviews address key questions about the translation of precision medicine research into practice. Although not complete, owing to the vast literature on this topic, they revealed opportunities for the immediate or near-term clinical implementation of precision diabetes medicine; furthermore, we expose important gaps in knowledge, focusing on the need to obtain new clinically relevant evidence. Gaps include the need for common standards for clinical readiness, including consideration of cost-effectiveness, health equity, predictive accuracy, liability and accessibility. Key milestones are outlined for the broad clinical implementation of precision diabetes medicine.

Understanding Implementation of Evidence-Based Interventions to Address Human Papillomavirus Vaccination: Qualitative Perspectives of Middle Managers

Engaging individuals in middle management positions (eg, nurse or clinic managers) could facilitate implementation of evidence-based interventions (EBIs) to improve uptake of human papillomavirus (HPV) vaccination. Our goal was to understand middle managers' role in and perspectives on implementation of EBIs for HPV vaccination. We conducted qualitative interviews with middle managers in pediatric and family practice clinics. We used constructs from the Consolidated Framework for Implementation Research (CFIR) to design the interview guide and as a coding framework. Participants (n = 19) reported overseeing implementation related to HPV vaccination. Across interviews, CFIR inner setting constructs (eg, structural characteristics and implementation climate) were identified as being both barriers and facilitators. As evidenced in this study, middle managers have a deep understanding of organizational factors, and they have the ability to facilitate implementation efforts related to HPV vaccination. Future efforts could focus on engaging middle managers and leveraging their expertise and understanding of barriers and facilitators.

Claims in the clinic: A qualitative group interview study on healthcare communication about unestablished side effects of the copper IUD

BACKGROUND

Lay online communication about health-related issues has in recent years largely been associated with the spread of misinformation and decreased trust in healthcare. Such communication has included claims about systemic side effects of the copper IUD. In Sweden, a social media group centered on this issue now gathers around 8,700 members. This study aimed to use the case of reported yet unestablished side effects of the copper IUD to investigate experiences of and reasoning about healthcare encounters between caregivers and patients contesting established medical knowledge.

METHODS

We conducted qualitative, semi-structured, digital group interviews with members of the social media group (seven groups, n = 23) and with midwives and gynecologists (six groups, n = 15). We also gathered essays written by social media group members (n = 23). The material was analyzed thematically.

RESULTS

The participant accounts pointed towards tensions related to principles of evidence-based medicine, i.e., perceived insufficiency of research on the safety of the copper IUD and lack of clarity in routines for reporting and following up suspected side effects, and of patient-centered care, i.e., listening respectfully to patients. Tension between caregivers' obligation to adhere to evidence-based medicine while also providing patient-centered care was noted.

CONCLUSION

Healthcare providers' efforts to assess and address patient claims contesting established medical knowledge should include ensuring and communicating sufficient research, clarifying procedures for reporting suspected side effects, and improving person-centered care. This can increase the quality of care while contributing to the mitigation of distrust in healthcare and the spreading of health-related misinformation.

Involving Voters and Consumers in Decision-Making about the Health Care System - The Swiss Case: A Review

BACKGROUND

Behind the principle of involving users and voters directly in decision-making about the health care system are ideas relating to empowerment. This implies a challenge to the traditional view that scientific knowledge is generally believed to be of higher value than empirical knowledge, as it is the case with CAM. The objectives of this review are (a) to show that this assumption disregards the fact that CAM is as scientific as conventional medicine but has different basic assumptions what the world is being made of and consequently uses different/adapted scientific methods; (b) to demonstrate how a perspective of the history of medicine and science as well as direct democracy mechanisms such as stipulated in the Swiss constitution can be used to achieve the acceptance of CAM in a modern medical health care system. A public health care system financed by levies from the population should also reflect the widely documented desire in the population for medical pluralism (provided that therapeutical alternatives are not risky). Otherwise, the problem of social inequality arises because only people with a good financial background can afford this medicine.

SUMMARY

From the perspective of scientific theory and the history of science, the answer to the question of whether complementary medicine and conventional medical procedures must provide proof of efficacy according to a uniform scientific is quite controversial according to epistemologically oriented studies on this issue.

KEY MESSAGES

This review found strong evidence for involving voters and consumers directly in decision-making about the provision of CAM in the health care system. It also seems necessary to step back in the debate on evidence-based medicine, taking a history of medicine and science perspective, as the role which the proper method occupies and plays in medicine is defined by the scientific nature of the world view.

Hinter dem Grundsatz, Nutzer und Wähler direkt in die Entscheidungsfindung über das Gesundheitssystem einzubeziehen, stehen Vorstellungen von Empowerment. Dies impliziert eine Infragestellung der traditionellen Ansicht, dass wissenschaftliches Wissen im Allgemeinen als wertvoller angesehen wird als empirisches Wissen und erprobte Erfahrung, wie es bei der Komplementärmedizin der Fall ist. Die Ziele dieser Übersichtsarbeit sind: (a) zu zeigen, dass diese Annahme die Tatsache außer Acht lässt, dass die Komplementärmedizin ebenso wissenschaftlich ist wie die Schulmedizin, aber von anderen Grundannahmen ausgeht, wie die Welt beschaffen ist, und folglich andere/angepasste wissenschaftliche Methoden anwendet; (b) aufzuzeigen, wie eine medizin- und wissenschaftsgeschichtliche Perspektive sowie Mechanismen der direkten Demokratie, wie sie in der Schweizer Verfassung vorgesehen sind, genutzt werden können, um die Akzeptanz der Komplementärmedizin in einem modernen medizinischen Gesundheitssystem zu erreichen. Ein öffentliches, durch Abgaben der Bevölkerung finanziertes Gesundheitssystem sollte auch dem vielfach dokumentierten Wunsch der Bevölkerung nach medizinischem Pluralismus Rechnung tragen (sofern die therapeutischen Alternativen nicht riskant sind). Andernfalls stellt sich das Problem der sozialen Ungleichheit, weil sich nur Menschen mit einem guten finanziellen Hintergrund diese Medizin leisten können.

Does the advertisement in Swiss pharmacy windows rest on evidence-based medicine? An observational study

OBJECTIVES

The aim of the study was to analyse the proportion of evidence-based medication displayed in pharmacies and compare it between the different linguistic regions of the country, at different times of the year to determine the amount of proven effective medications indirectly recommended to the public in different parts of Switzerland.

DESIGN

This is an observational study conducted by medical doctors in the department of internal medicine at the Spitalzentrum Biel, Switzerland.

SETTING

The observation took place from July 2019 to May 2020. From a total of 1800 pharmacies in Switzerland, 68 different pharmacies were selected across the 3 main linguistic regions and the medication on display in their windows were examined 4 times a year regarding their efficacy. The displays of medication with or without evidence-based efficacy were described using absolute numbers and proportions and compared between the different linguistic regions at different seasons using χ2.

PARTICIPANTS

There were no human or animal participants involved in this study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome is the proportion of medication displayed in pharmacy windows with a proven effectiveness in medical literature. The secondary outcome was the variability of the primary outcome over time (seasonal changes), over the different linguistic regions of Switzerland and between chains and privately owned pharmacies.

RESULTS

We examined 970 medications and found that over the whole year, there is a high proportion of non-evidence-based drugs (56,9%) displayed in pharmacies. Swiss German cantons display significantly more non-evidence-based medications in winter. We found no statistical difference for other seasons or between chains and privately owned pharmacies.

CONCLUSION

Pharmacies in Switzerland tend to display significantly more non-evidence-based drugs, thus indirectly recommending them to the public. In a time of necessary expansion of self-medication by the population, this could incite consumers to buy drugs without proven effectiveness.

[Construction of jingjin differentiation system based on holistic concept]

As a diagnostic method to guide the treatment of sinew/fascia diseases, jingjin (muscle regions of meridians) differentiation is an important component of syndrome differentiation system of acupuncture and moxibustion. In clinical practice, because of the limitations of the ideological guidance of the holistic view, the systemic and dialectical thinking and the syndrome element collection, the system of diagnosis and treatment of sinew/fascia diseases is not comprehensive. Through combing the origin of the holistic view of jingjin, the paper expounds the differentiation framework of sinew/fascia diseases from 4 aspects of differentiation, i.e. the location of disease, etiology, nature of disease and condition of disease. It suggests to construct jingjin differentiation system by taking the holistic ideas as the core, the syndrome element research as the common method and the evidence-based medicine as the theoretical basis so that the thinking of syndrome differentiation and the diagnostic approaches based on jingjin theory can be enriched.

Guidelines for high-flow nasal cannula oxygen therapy in neonates (2022)

High-flow nasal cannula (HFNC) oxygen therapy, which is important in noninvasive respiratory support, is increasingly being used in critically ill neonates with respiratory failure because it is comfortable, easy to setup, and has a low incidence of nasal trauma. The advantages, indications, and risks of HFNC have been the focus of research in recent years, resulting in the development of the application. Based on current evidence, we developed guidelines for HFNC in neonates using the Grading of Recommendations Assessment, Development and Evaluation (GRADE). The guidelines were formulated after extensive consultations with neonatologists, respiratory therapists, nurse specialists, and evidence-based medicine experts. We have proposed 24 recommendations for 9 key questions. The guidelines aim to be a source of evidence and reference of HFNC oxygen therapy in clinical practice, and so that more neonates and their families will benefit from HFNC.

A systematic review of the effectiveness of journal clubs in undergraduate medicine

Background

Training future doctors in the skills of evidence-based medicine (EBM) is clearly important. Journal club (JCs) are well-recognized educational interventions for teaching EBM. In contrast to postgraduate medical education, JCs use in undergraduate medical education (UME) has not been adequately explored. We conducted a realist review of the effectiveness of JCs in UME to unpack the underlying mechanisms by which the intervention works (or fails) in teaching EBM.

Methods

The scope of review was the evaluation of the effectiveness of JCs in UME settings. We searched major bibliographic databases - MEDLINE, Embase, ERIC, PSYCInfo, CINAHL, Scopus, and Web of Science and found fifteen articles eligible for inclusion. Data was extracted aided by a modified Kirkpatrick framework and presented in evidence tables. Themes and chains of inference were identified, and finally, we formulated new hypotheses on how and why JC intervention works.

Results

Mandatory vs. voluntary JC did not differentially impact attendance of JC in UME settings though JC duration beyond two hours decreased attendees' self-reported satisfaction. Coupling lectures to JCs positively impacts knowledge gain and retention. Coupled Mentorship or using critical appraisal worksheets helped the achievement of manuscript writing skills and a positive attitude towards EBM.

Conclusions

Journal clubs are effective interventions to teach EBM in UME settings and are well-received by learners. They improve specific learning outcomes of knowledge gain and retention, skills of manuscript writing and critical appraisal. However, we found no evidence that these translates to the practice of EBM nor impacts patient outcomes.

The Top 100 Cited Articles in the Microsurgical Treatment for Lymphedema

BACKGROUND

 Evidence-based medicine uses the current best evidence for decisions about patient care. Lymphedema is a chronic debilitating medical condition caused by a dysfunctional lymphatic system. This study analyzes the most cited articles, including the levels of evidence, for the surgical treatment of lymphedema.

METHODS

 The Web of Science Sci-Expanded Index was utilized to search for surgical treatment of lymphedema. Articles were examined by three independent reviewers and the top 100 articles were determined. The corresponding author, citation count, publication year, topic, study design, level of evidence, journal, country, and institution were analyzed.

RESULTS

 Since 1970, the top 100 articles have been cited 7,300 times. The average citation count was 68 and standard deviation was 55. The majority was case series (71), followed by retrospective cohort (8), prospective cohort (7), retrospective case-control (5), and randomized controlled trials (2). Based on the "Level of Evidence Pyramid," 71 articles were level IV, 13 articles were level III, and 9 articles were level II. On the Grading of Recommendations Assessment, Development, and Evaluation Scale, there were 71 articles with "very low," 20 articles with "low," and 2 articles with "moderate" quality of evidence.

CONCLUSION

 The top 100 cited articles were mostly case series and lacked high levels of evidence. Most studies are retrospective case series with short-term outcomes. However, low level evidence for new surgical procedures is to be expected. Current trends suggest the treatment and understanding of lymphedema will continue to improve.

Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service?

BACKGROUND

Health systems are under pressure to maintain services within limited resources. The Evidence-Based Interventions (EBI) programme published a first list of guidelines in 2019, which aimed to reduce inappropriate use of interventions within the NHS in England, reducing potential harm and optimising the use of limited resources. Seventeen procedures were selected in the first round, published in April 2019.

METHODS

We evaluated changes in the trends for each procedure after its inclusion in the EBI's first list of guidelines using interrupted time series analysis. We explored whether there was any evidence of spill-over effects onto related or substitute procedures, as well as exploring changes in geographical variation following the publication of national guidance.

RESULTS

Most procedures were experiencing downward trends in the years prior to the launch of EBI. We found no evidence of a trend change in any of the 17 procedures following the introduction of the guidance. No evidence of spill-over increases in substitute or related procedures was found. Geographic variation in the number of procedures performed across English CCGs remained at similar levels before and after EBI.

CONCLUSIONS

The EBI programme had little success in its aim to further reduce the use of the 17 procedures it deemed inappropriate in all or certain circumstances. Most procedure rates were already decreasing before EBI and all continued with a similar trend afterwards. Geographical variation in the number of procedures remained at a similar level post EBI. De-adoption of inappropriate care is essential in maintaining health systems across the world. However, further research is needed to explore context specific enablers and barriers to effective identification and de-adoption of such inappropriate health care to support future de-adoption endeavours.

Evaluating the Certainty of Evidence in Evidence-based Medicine

Certainty of evidence (formerly known as quality of evidence) is defined as the extent to which our confidence in an estimate of the effect is correct or our certainty that such estimate supports a particular recommendation for a clinical practice guideline. Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) is a structured and reproducible framework for assigning a level of certainty on a per-outcome basis for evidence derived from randomized and nonrandomized studies. The level of certainty starts as high or low and can be increased or decreased after considering several criteria (eg, risk of bias, inconsistency of results, publication bias, dose-response gradient, large magnitude of effect, among others). Here we describe in brief the GRADE process for summarizing and assigning a certainty rating for evidence. PATIENT SUMMARY: The GRADE framework is a way to work out how much we can trust results from medical research studies. This helps doctors in making informed decisions with their patients.

Qualitative study of guideline panelists: innovative surveys provided valuable insights regarding patient values and preferences

OBJECTIVES

To explore guideline panelists' understanding of panel surveys for eliciting panels' inferences regarding patient values and preferences, and the influence of the surveys on making recommendations.

STUDY DESIGN AND SETTING

We performed sampling and data collection from all four guideline panels that had conducted the surveys through October 2020. We collected the records of all panel meetings and interviewed some panelists in different roles. We applied inductive thematic analysis for analyzing and interpreting data.

RESULTS

We enrolled four guideline panels with 99 panelists in total and interviewed 25 of them. Most panelists found the survey was easy to follow and facilitated the incorporation of patient values and preferences in the tradeoffs between benefits and harms or burdens. The variation of patient preferences and uncertainty regarding patient values and preferences reflected in the surveys helped the panels ponder the strength of recommendations. In doing so, the survey results enhanced a rationale for panels' decision on the recommendations.

CONCLUSION

The panel surveys have proved to help guideline panels explicitly consider and incorporate patient values and preferences in making recommendations. Guideline panels would benefit from widespread use of the panel surveys, particularly when primary evidence regarding patient values and preferences is scarce.

Advances in the adaptation and implementation of evidence-based interventions for historically marginalized groups

This collection of six articles showcases innovative approaches to adapting and deploying evidence-based interventions with individuals from historically marginalized groups to advance mental health equity. The field of cultural adaptation has matured beyond initial questions about whether specific culturally adapted interventions work, and must now adopt designs that can yield generalizable knowledge concerning how and under what circumstances such adaptations can promote improved engagement and effectiveness with underserved groups. Crucial to this goal is identifying the target mechanisms presumed to underlie poorer clinical and engagement outcomes among minoritized groups that must be addressed by the adaptation. Furthermore, contributors have gone beyond adaptations to EBI therapeutic content and processes, to the mobilization of implementation strategies that increase the reach and impact of EBIs outside conventional service settings. Our featured investigators have also illuminated critical modifications to the entire research enterprise to center community needs in the conduct of intervention research with historically marginalized groups. We are grateful for the opportunity to highlight these contributions spanning intervention science, adaptation science, and implementation science in Behaviour Research and Therapy.

Cost of Implementing an Evidence-Based Intervention to Support Safer Use of Antipsychotics in Youth

To estimate the cost of implementing a clinical program designed to support safer use of antipsychotics in children and adolescents (youth) age 3-17 years at the time of initiating an antipsychotic medication. We calculate the costs of implementing a psychiatric consultation and navigation program for youth prescribed antipsychotic medications across 4 health systems, which included an electronic health record (EHR) decision support tool, consultation with a child and adolescent psychiatrist, and up to 6 months of behavioral health care navigation, as well as telemental health for patients (n = 348). Cost data were collected for both start-up and ongoing intervention phases and are estimated over a 1-year period. Data sources included study records and time-in-motion reports, analyzed from a health system perspective. Costs included both labor and nonlabor costs (2019 US dollars). The average total start-up and ongoing costs per health system were $34,007 and $185,174, respectively. The average total cost per patient was $2,128. The highest average ongoing labor cost components were telemental health ($901 per patient), followed by child and adolescent psychiatrist consultation ($659), and the lowest cost component was primary care/behavioral health provider time to review/respond to the EHR decision support tool and case consultation ($24). For health systems considering programs to promote safer and targeted use of antipsychotics among youth, this study provides estimates of the full start-up and ongoing costs of an EHR decision support tool, psychiatric consultation service, and psychotherapeutic services for patients and families.Trial registration: Clinicaltrials.gov, NCT03448575.

Use of Evidence-Based Interventions to Promote Healthy Weight, Nutrition, and Physical Activity in Community Health Improvement Plans from Large Local Health Departments

We sought to identify evidence-based healthy weight, nutrition, and physical activity strategies related to obesity prevention in large local health department (LHD) Community Health Improvement Plans (CHIPs). We analyzed the content of the most recent, publicly available plans from 72 accredited LHDs serving a population of at least 500 000 people. We matched CHIP strategies to the County Health Rankings and Roadmaps' What Works for Health (WWFH) database of interventions. We identified 739 strategies across 55 plans, 62.5% of which matched a "WWFH intervention" rated for effectiveness on diet and exercise outcomes. Among the 20 most commonly identified WWFH interventions in CHIPs, 10 had the highest evidence for effectiveness while 4 were rated as likely to decrease health disparities according to WWFH. Future prioritization of strategies by health agencies could focus on strategies with the strongest evidence for promoting healthy weight, nutrition, and physical activity outcomes and reducing health disparities.

Rapid Reviews to Support Practice: A Guide for Professional Organization Practice Networks

Background. Occupational Therapists, among other healthcare decision makers, often need to make decisions within limited timeframes and cannot wait for the completion of large rigorous systematic reviews and meta-analyses. Rapid reviews are one method to increase the integration of research evidence into clinical decision making. Rapid reviews streamline the systematic review process to allow for the timely synthesis of evidence; however, there does not exist a single agreed upon guide for the methodology and reporting of rapid reviews. Purpose. This paper proposes a rapid review methodology that is customized to a professional organization practice which can feasibly be used by practice networks such as those of the Canadian Association for Occupational Therapy to conduct reviews. Implications. Practice networks provide a sustainable mechanism to integrate research evidence and foster communication amongst practitioners. This guide for conducting and reporting rapid reviews can be used across Occupational Therapy practice networks and similar groups to support the consistent and timely synthesis of evidence necessary to improve evidence-informed clinical decision making.

How to Conduct a Systematic Review and Meta-Analysis: A Guide for Clinicians

Evidence-based practice relies on using research evidence to guide clinical decision-making. However, staying current with all published research can be challenging. Many clinicians use review articles that apply predefined methods to locate, identify, and summarize all available evidence on a topic to guide clinical decision-making. This paper discusses the role of review articles, including narrative, scoping, and systematic reviews, to synthesize existing evidence and generate new knowledge. It provides a step-by-step guide to conducting a systematic review and meta-analysis, covering key steps such as formulating a research question, selecting studies, evaluating evidence quality, and reporting results. This paper is intended as a resource for clinicians looking to learn how to conduct systematic reviews and advance evidence-based practice in the field.

Evidence based Urology: The Gist Leading Us to the Evidence for Decisions

Making clinical decisions based on guideline recommendations that include relevant information and stakeholder perspectives requires a systematic approach that is transparent and clear. The evidence-to-decision framework helps clinicians, panel members, and policymakers to translate knowledge into patient care.

[Construction of clinical efficacy evaluation system based on optimal clinical experience]

Evidence-based medicine plays an important role in promoting the scientific nature of clinical decision-making. Howe-ver, there is a problem where evidence derived from clinical research may not necessarily be applicable to individual patients. Evidence-based medicine has been introduced into the field of traditional Chinese medicine(TCM) for over 20 years, and although certain achievements have been made, the overall level of clinical research evidence based on the principles of evidence-based medicine in TCM is not high. The acceptance of TCM diagnosis and treatment guidelines developed based on evidence-based medicine methods is generally low. As revealed by the analysis of the problems in the application of evidence-based medicine in the field of TCM, it is found that there is a structural contradiction between clinical randomized controlled trial(RCT) of TCM and the characteristics of TCM clinical practice. They cannot comprehensively, objectively, and truthfully reflect the clinical efficacy and safety of TCM. Conducting clinical RCTs of TCM in pursuit of "evidence" actually means giving up the advantages of TCM in clinical treatment based on syndrome differentiation, prescription changes along with syndromes, and treatment in accordance with three categories of disease cause, which leads to sacrificing some clinical effectiveness of TCM. Based on the concept of evidence-based medicine, this article proposed the construction of "clinical syndrome-based medicine" based on the optimal clinical experience, which was suitable for the characteristics of TCM clinical practice. The key to clinical syndrome-based medicine is the optimal clinical experience, and the core elements of the optimal clinical experience are regularity and reproducibility. Real-world research methods are recommended as a reference for obtaining the optimal clinical experience. Clinical syndrome-based medicine, combining the characteristics of TCM clinical practice and incorporating the concept of evidence-based medicine, is the product of integrating TCM into evidence-based medicine. It is dedicated to improving the clinical efficacy of TCM along with evidence-based medicine.

Update in Outpatient General Internal Medicine: Practice-Changing Evidence Published in 2022

It can be difficult for clinicians to stay updated on practice-changing articles.  Synthesis of relevant articles and guideline updates can facilitate staying informed on important new data impacting clinical practice.  The titles and abstracts from the 7 general internal medicine outpatient journals with highest impact factors and relevance were reviewed by 8 internal medicine physicians. Coronavirus disease 2019 research was excluded.  The New England Journal of Medicine (NEJM), The Lancet, the Journal of the American Medical Association, The British Medical Journal (BMJ), the Annals of Internal Medicine, JAMA Internal Medicine, and Public Library of Science Medicine were reviewed. Additionally, article synopsis collections and databases were reviewed: American College of Physicians Journal Club, NEJM Journal Watch, BMJ Evidence-Based Medicine, McMaster/DynaMed Evidence Alerts, and Cochrane Reviews. A modified Delphi method was used to gain consensus based on clinical relevance to outpatient internal medicine, potential impact on practice, and strength of evidence. Article qualities and importance were debated until consensus was reached. Clusters of articles pertinent to the same topic were considered together. In total, 5 practice-changing articles were included, along with a highlight of key guideline updates.

Common misunderstandings of evidence-based medicine

Currently, most evidence assessments in guidelines or health technology assessments (HTAs) rely on the assumption that a randomized controlled trial (RCT) is always the best source of evidence. However, if the outcome in a control group is certain, e.g. death within a short time with an almost 100% chance, or if an event can only occur in the treatment group, there is no need for a randomized control group; the evidence cannot be improved by a control group, nor by an RCT design. If a cause-effect relationship is certain ("primary or direct evidence"), a therapeutic effect can be diluted in the population of an RCT by cross-over, etc. This can lead to serious misinterpretations of the effect. While experts such as the GRADE group or Cochrane institutes recommend using all available evidence, the leading approach in many guidelines and HTAs is assessing "the best available trials", i.e. RCTs. But since RCTs only deliver probabilities of cause-effect relationships, it is not appropriate to demand RCTs for certain effects. A control group can only diminish the net value of a treatment since the outcome in the control group is subtracted from the outcome in the treatment group. Therefore, under identical circumstances, an RCT will always show lower effect rates compared to a single arm study of the same quality, for desired as well as for adverse effects. Considering these inconsistencies in evidence-based medicine interpretation, the evidence pyramid with RCTs at the top is not always a reliable indicator for the best quality of evidence.

Status and Quality of Guidelines for Therapeutic Drug Monitoring Based on AGREE II Instrument

BACKGROUND

With the progress of therapeutic drug monitoring (TDM) technology and the development of evidence-based medicine, many guidelines were developed and implemented in recent decades.

OBJECTIVE

The aim was to evaluate the current status of TDM guidelines and provide suggestions for their development and updates based on Appraisal of Guidelines for Research and Evaluation (AGREE) II.

METHODS

The TDM guidelines were systematically searched for among databases including PubMed, Embase, China National Knowledge Infrastructure, Wanfang Data, and the Chinese biomedical literature service system and the official websites of TDM-related associations. The search period was from inception to 6 April 2023. Four researchers independently screened the literature and extracted data. Any disagreement was discussed and reconciled by another researcher. The quality of guidelines was assessed using the AGREE II instrument.

RESULTS

A total of 92 guidelines were included, including 57 technical guidelines, three management guidelines, and 32 comprehensive guidelines. The number of TDM guidelines has gradually increased since 1979. The United States published the most guidelines (20 guidelines), followed by China (15 guidelines) and the United Kingdom (ten guidelines), and 23 guidelines were developed by international organizations. Most guidelines are aimed at adult patients only, while 28 guidelines include special populations. With respect to formulation methods, there are 23 evidence-based guidelines. As for quality evaluation results based on AGREE II, comprehensive guidelines scored higher (58.16%) than technical guidelines (51.36%) and administrative guidelines (50.00%).

CONCLUSION

The number of TDM guidelines, especially technical and comprehensive ones, has significantly increased in recent years. Most guidelines are confronted with the problems of unclear methodology and low quality of evidence according to AGREE II. More evidence-based research on TDM and high-quality guideline development is recommended to promote individualized therapy.

The effect of capacity building evidence-based medicine training on its implementation among healthcare professionals in Southwest Ethiopia: a controlled quasi-experimental outcome evaluation

BACKGROUND

Evidence-based medicine (EBM) bridges research and clinical practice to enhance medical knowledge and improve patient care. However, clinical decisions in many African countries don't base on the best available scientific evidence. Hence, this study aimed to determine the effect of training interventions on background knowledge and awareness of EBM sources, attitude, competence, and practice of EBM among healthcare professionals.

METHOD

We designed a controlled group quasi-experimental pre-post test study to evaluate the effect of capacity-building EBM training. A total of 192 healthcare professionals were recruited in the study (96 from the intervention and 96 from the control group). We used a difference-in-differences (DID) analysis to determine the effect of the training. Along the way, we used a fixed effect panel-data regression model to assess variables that could affect healthcare professionals' practice of EBM. The cut point to determine the significant effect of EBM training on healthcare professionals' background knowledge and awareness of EBM sources, attitude, and competence was at a P-value < 0.05.

RESULT

The DID estimator showed a significant net change of 8.0%, 17.1%, and 11.4% at P < 0.01 on attitude, competence, and practice of EBM, respectively, whereas no significant increment in the background knowledge and awareness of EBM sources. The fixed effect regression model showed that the attitude [OR = 2.288, 95% CI: (1.049, 4.989)], competence [OR = 4.174, 95% CI: 1.984, 8.780)], technical support [OR = 2.222, 95% CI: (1.043, 3.401)], and internet access [OR = 1.984, 95% CI: (1.073, 4.048)] were significantly affected EBM practice.

CONCLUSION

The capacity-building training improved attitude, competence, and EBM practice. Policymakers, government, and other concerned bodies recommended focusing on a well-designed training strategy to enhance the attitude, competence, and practice towards EBM among healthcare professionals. It was also recommended to enhance internet access and set mechanisms to provide technical support at health facilities.

How are countries responding differently to COVID-19: a systematic review of guidelines on isolation measures

Introduction

Isolation strategies have been implemented in numerous countries worldwide during the ongoing community transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). However, various countries and organizations have implemented their isolation measures at varying intensities, even during the same period. Therefore, we systematically reviewed the key information contained in currently available guidelines regarding the isolation of the general population, aiming to better identify the heterogeneity of the current isolation strategies.

Methods

We conducted searches in four evidence-based medicine (EBM) databases and five guideline websites to identify guidelines, guidance, protocols, and policy documents published by authoritative advisory bodies or healthcare organizations, which provided information on the implementation of isolation for general populations with COVID-19. One author extracted data using a standardized data extraction checklist, and a second author double-checked all extractions for completeness and correctness. Discrepancies were resolved through discussion. The information extracted from the included articles was summarized both narratively and using tables.

Results

We included 15 articles that provided information on isolation measures recommended by nine different countries and organizations. The included articles consistently recommended isolating individuals with a positive COVID-19 test, regardless of the presence of symptoms. However, there were variations in the duration of isolation, and substantial differences also existed in the criteria for ending the isolation of COVID-19 patients.

Conclusion

Different countries and organizations have substantial differences in their isolation policies. This reminds us that scientifically sound guidelines on isolation that balance the risk of prematurely ending isolation with the burden of prolonged isolation are a crucial topic of discussion when faced with a pandemic.

How to review and assess a systematic review and meta-analysis article: a methodological study (secondary publication)

Systematic reviews and meta-analyses have become central in many research fields, particularly medicine. They offer the highest level of evidence in evidence-based medicine and support the development and revision of clinical practice guidelines, which offer recommendations for clinicians caring for patients with specific diseases and conditions. This review summarizes the concepts of systematic reviews and meta-analyses and provides guidance on reviewing and assessing such papers. A systematic review refers to a review of a research question that uses explicit and systematic methods to identify, select, and critically appraise relevant research. In contrast, a meta-analysis is a quantitative statistical analysis that combines individual results on the same research question to estimate the common or mean effect. Conducting a meta-analysis involves defining a research topic, selecting a study design, searching literature in electronic databases, selecting relevant studies, and conducting the analysis. One can assess the findings of a meta-analysis by interpreting a forest plot and a funnel plot and by examining heterogeneity. When reviewing systematic reviews and meta-analyses, several essential points must be considered, including the originality and significance of the work, the comprehensiveness of the database search, the selection of studies based on inclusion and exclusion criteria, subgroup analyses by various factors, and the interpretation of the results based on the levels of evidence. This review will provide readers with helpful guidance to help them read, understand, and evaluate these articles.

Use of a toolbox of tailored evidence-based interventions to improve children's physical activity and cardiorespiratory fitness in primary schools: results of the ACTIPROS cluster-randomized feasibility trial

BACKGROUND

School-based physical activity (PA) promotion is usually conducted by providing one specific intervention. In contrast, the ACTIvity PROmotion via Schools (ACTIPROS) toolbox provides a set of twelve evidence-based PA interventions serving different domains of the Health Promoting Schools framework that primary schools can select according to their requirements. In this study, we tested the feasibility of the toolbox approach in primary schools.

METHODS

A two-arm cluster-randomized feasibility trial at primary schools (n = 5 intervention schools [IS], n = 5 control schools) located in the Federal State of Bremen, Germany, was conducted. Children's habitual PA (GENEActiv, Activinsights Ltd.) and motor skills (Deutscher Motorik Test; DMT) were measured at the beginning (t0: Sept and Oct 2021) and at the end of the school year (t1: June and July 2022). Between Oct 2021 and July 2022, the ACTIPROS toolbox was implemented at IS. Teachers documented intervention choices and implementation within a short questionnaire (SIQ) at t1.

RESULTS

IS successfully implemented at least one intervention of the toolbox. In total, seven out of twelve possible interventions were selected. Two schools decided to replace an intervention with another during the trial. Results of the SIQ indicated that IS tended to choose similar interventions while implementation frequency was highly different. N = 429 students from two classes per school were recruited. The mean consent rate was 75.1% (n = 322). At t0 and t1, n = 304 (94.4%) and n = 256 (79.3%) of consented children took part in the DMT, respectively. The accelerometry sample included one class per participating school. At t0 and t1, n = 166 and n = 151 devices were handed out to students and n = 133 (80.1%) and n = 106 (70.2%) valid records could be retrieved, respectively. Linear mixed models showed an intervention effect of 15.5 min (95% CI: 4.5; 26.6) in children's daily MVPA at IS between t0 and t1 compared to controls.

CONCLUSIONS

All IS were able to implement at least one intervention from the toolbox, and unsuitable interventions were successfully replaced in a timely manner, highlighting the feasibility of implementing the ACTIPROS toolbox. Good consent rates for accelerometer and motor skills data were achieved. Results indicate a substantial increase in MVPA associated with the ACTIPROS toolbox and need to be tested in a larger sample.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00025840.

Real World Evidence: methodological issues and opportunities from the European Health Data Space

The current Evidence-Based-Medicine (EBM) approach is generally based on data coming from Randomized Clinical Trials or and, epidemiological observational studies. However, the past few years, with the explosion of available data derived from e-technology, a novel aspect regarding EBM arose, the Real-World-Data (RWD). RWD refers to data collected outside traditional studies, such as e-health records, claims data, patient-generated information, registries, etc. This type of information provides invaluable insights into the effectiveness, safety, and value of medical treatments and interventions when applied in real world settings. European Health Data Space (EHDS) is an initiative launched by the European Commission to create a secure and protected platform for exchanging health data across borders within European Union. The powerful combination of RWD within the EHDS serves as a valuable resource, supporting research initiatives. By analyzing diverse RWD sources, researchers generate Real-World Evidence (RWE) broadening medical knowledge. In this comment paper, methodological issues and opportunities of the application of EHDS in member states are discussed. Undoubtedly, EHDS creates a health-specific ecosystem empowering individuals through increased digital access and control their health data, providing a consistent, truthful and proficient set-up for the use of health data for research, innovation, policy-making and regulatory activities.

Rescinding evidence-based care and practices during the initial COVID-19 outbreak in the United States: a qualitative study of the experiences of lactation support providers

Background

The COVID-19 pandemic disrupted healthcare systems and services including along the childbearing continuum. The aim of this study was to explore the experiences and perceptions of professional lactation support providers who cared for breastfeeding families during the early months of the pandemic (March 2020 - August 2020) in the United States.

Design/methods

We conducted a qualitative survey among active lactation support providers in the United States. Eligible participants spoke English, were Certified Lactation Counselors who maintained an active certification and who provided lactation care and services prior to and after the onset of the COVID-19 pandemic. Participants were recruited via email from the national database of Certified Lactation Counselors obtained from the national certification body. All ten Health and Human Service regions of the United States were included. Demographic data was collected on each respondent. Qualitative survey responses were analyzed thematically following the framework method.

Findings

Six-hundred and seventy-four (674) Certified Lactation Counselors responded to the survey from June to July of 2022. Their responses fell within the overarching theme of rescinding evidence-based care and practices that had been in place prior to the pandemic. Affected care practices included the insertion of limits on access to care and insinuating stigma and bias based on COVID-19 status. Irregular appointment schedules and staffing shortages also affected care. Participants reported that separation of the mother and their infant became the norm. Decisions made by management seemed to be grounded in fear and uncertainty, rather than on the evidence-based principles that had been in place prior to the pandemic.

Conclusion

A lack of coordination, consistency and support, along with fear of the unknown, troubled lactation support providers and impacted their ability to provide evidence-based care and to maintain access to care for all families. The findings of the survey and analysis underscore the importance of adequately preparing for future public health crises by determining how evidence-based care and practices can be preserved in emergent situations.

Becoming a Phronimos: Evidence-Based Medicine, Clinical Decision Making, and the Role of Practical Wisdom in Primary Care

There has been much discussion about the overmedicalization of human experience and the problems incurred by overzealous action-oriented medical care. In this paper we describe the Aristotelean virtue of phronesis, or practical wisdom, and discuss how it can be developed by interested clinicians. We argue that becoming a phronimos requires conscious attention to one's practice by using feedback to continually improve. But there must also be judicious adherence to clinical practice guidelines and advocacy for people-as-patients at individual, community, and national levels.

Systematic review of sample size calculations and reporting in randomized controlled trials in ophthalmology over a 20-year period

PURPOSE

Randomized Controlled Trials (RCTs) are considered the gold standard for the practice of evidence-based medicine. The purpose of this study is to systematically assess the reporting of sample size calculations in ophthalmology RCTs in 5 leading journals over a 20-year period. Reviewing sample size calculations in ophthalmology RCTs will shed light on the methodological quality of RCTs and, by extension, on the validity of published results.

METHODS

The MEDLINE database was searched to identify full reports of RCTs in the journals Ophthalmology, JAMA Ophthalmology, American Journal of Ophthalmology, Investigative Ophthalmology and Visual Science, and British Journal of Ophthalmology between January and December of the years 2000, 2010 and 2020. Screening identified 559 articles out of which 289 met the inclusion criteria for this systematic review. Data regarding sample size calculation reporting and trial characteristics was extracted for each trial by independent investigators.

RESULTS

In 2020, 77.9% of the RCTs reported sample size calculations as compared with 37% in 2000 (p < 0.001) and 60.7% in 2010 (p = 0.012). Studies reporting all necessary parameters for sample size recalculation increased significantly from 17.2% in 2000 to 39.3% in 2010 and 43.0% in 2020 (p < 0.001). Reporting of funding was greater in 2020 (98.8%) compared with 2010 (89.3%) and 2000 (53.1%). Registration in a clinical trials database occurred more frequently in 2020 (94.2%) compared to 2000 (1.2%; p < 0.001) and 2010 (68%; p < 0.001). In 2020, 38.4% of studies reported different sample sizes in the online registry from the published article. Overall, the most studied area in 2000 was glaucoma (29.6% of RCTs), whereas in 2010 and 2020, it was retina (40.2 and 37.2% of the RCTs, respectively). The number of patients enrolled in a study and the number of eyes studied was significantly greater in 2020 compared to 2000 and 2010 (p < 0.001).

CONCLUSION

Sample size calculation reporting in ophthalmology RCTs has improved significantly between the years 2000 and 2020 and is comparable to other fields in medicine. However, reporting of certain parameters remains inconsistent with current publication guidelines.

Consensus Practice Guidelines on Postdural Puncture Headache From a Multisociety, International Working Group: A Summary Report

Importance

Postdural puncture headache (PDPH) can follow unintentional dural puncture during epidural techniques or intentional dural puncture during neuraxial procedures, such as a lumbar puncture or spinal anesthesia. Evidence-based guidance on the prevention, diagnosis, and management of this condition is, however, currently lacking.

Objective

To fill the practice guidelines void and provide comprehensive information and patient-centric recommendations for preventing, diagnosing, and managing PDPH.

Evidence Review

With input from committee members and stakeholders of 6 participating professional societies, 10 review questions that were deemed important for the prevention, diagnosis, and management of PDPH were developed. A literature search for each question was performed in MEDLINE on March 2, 2022. Additional relevant clinical trials, systematic reviews, and research studies published through March 2022 were also considered for practice guideline development and shared with collaborator groups. Each group submitted a structured narrative review along with recommendations that were rated according to the US Preventive Services Task Force grading of evidence. Collaborators were asked to vote anonymously on each recommendation using 2 rounds of a modified Delphi approach.

Findings

After 2 rounds of electronic voting by a 21-member multidisciplinary collaborator team, 47 recommendations were generated to provide guidance on the risk factors for and the prevention, diagnosis, and management of PDPH, along with ratings for the strength and certainty of evidence. A 90% to 100% consensus was obtained for almost all recommendations. Several recommendations were rated as having moderate to low certainty. Opportunities for future research were identified.

Conclusions and Relevance

Results of this consensus statement suggest that current approaches to the treatment and management of PDPH are not uniform due to the paucity of evidence. The practice guidelines, however, provide a framework for individual clinicians to assess PDPH risk, confirm the diagnosis, and adopt a systematic approach to its management.

Management of Acetaminophen Poisoning in the US and Canada: A Consensus Statement

Importance

The US and Canada currently have no formal published nationwide guidelines for specialists in poison information or emergency departments for the management of acetaminophen poisoning, resulting in significant variability in management.

Objective

To develop consensus guidelines for the management of acetaminophen poisoning in the US and Canada.

Evidence Review

Four clinical toxicology societies (America's Poison Centers, American Academy of Clinical Toxicology, American College of Medical Toxicology, and Canadian Association of Poison Control Centers) selected participants (n = 21). Led by a nonvoting chairperson using a modified Delphi method, the panel created a decision framework and determined the appropriate clinical management of a patient with acetaminophen poisoning. Unique to this effort was the collection of guidelines from most poison centers in addition to systematic collection and review of the medical literature. Comments from review by external organizations were incorporated before the guideline was finalized. The project began in March 2021 and ended in March 2023.

Findings

The search retrieved 84 guidelines and 278 publications. The panel developed guidelines for emergency department management of single or repeated ingestion of acetaminophen. In addition, the panel addressed extended-release formulation, high-risk ingestion, coingestion of anticholinergics or opioids, age younger than 6 years, pregnancy, weight greater than 100 kg, and intravenous acetaminophen use. Differences from current US practice include defining acute ingestion as an ingestion presentation from 4 to 24 hours after overdose was initiated. A revised form of the Rumack-Matthew nomogram was developed. The term massive ingestion was replaced with the term high-risk ingestion and denoted by a specific nomogram line. Other recommendations include specific criteria for emergency department triage, laboratory evaluation and monitoring parameters, defining the role of gastrointestinal decontamination, detailed management of acetylcysteine treatment, associated adverse effects, and stopping criteria for acetylcysteine treatment, as well as criteria for consultation with a clinical toxicologist. Finally, specific treatment considerations, including acetylcysteine dosing, fomepizole administration, and considerations for extracorporeal elimination and transplant evaluation, were addressed.

Conclusions and Relevance

This qualitative study provides a consensus statement on consistent evidence-based recommendations for medical, pharmacy, and nursing education and practice to optimize care of patients with acetaminophen poisoning.

Different Techniques and Quantitative Measurements in Upper lip lift: A Systematic Review

BACKGROUND

The upper lip area is an important component of facial aesthetics, and aging produces an increase in the vertical height of the upper lip. Different upper lip lifting techniques are described in the literature.

OBJECTIVES

This systematic review aimed to assess both invasive and noninvasive upper lip lifting techniques with patient satisfaction, adverse effects, and quantitative measurements of lifting efficiency.

METHODS

This study was conducted per PRISMA guidelines. MEDLINE (via PubMed), EMBASE (OvidSP), and Cochrane Library database were searched from September 14, 2022, to October 12, 2022. Inclusion criteria were reporting on upper lip lift efficiency with quantitative measurements of the lifting degree.

RESULTS

Out of 495 studies through the search strategy, nine articles were included in the systematic review, eight for surgical procedures and one for nonsurgical. Surgical procedures seem to have better longevity than nonsurgical techniques. Reported patient satisfaction for both surgical and nonsurgical treatments was good with no severe complaints. The quantitative measures differ between researches and may be classified into two metrics: anatomy ratio computation using photographic analysis or direct height measurement with a caliper and precise parameters utilizing a three-dimensional method.

CONCLUSION

In general, surgical therapies seem to have a longer-lasting lifting effect on upper lip lifts with an inevitable scar, while nonsurgical techniques are minimally invasive but temporary. There was a lack of consistency in the measurements used to assess lifting efficiency. A consistent quantitative assessment can be beneficial for both clinical decision-making and high-level evidence research.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .